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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601880
Report Date: 08/14/2023
Date Signed: 08/14/2023 01:59:07 PM

Document Has Been Signed on 08/14/2023 01:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LUBEC HOMEFACILITY NUMBER:
198601880
ADMINISTRATOR:RONALD YUSONFACILITY TYPE:
734
ADDRESS:9294 LUBEC STREETTELEPHONE:
(562) 923-0900
CITY:DOWNEYSTATE: CAZIP CODE:
90240
CAPACITY: 5CENSUS: 5DATE:
08/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:Ronald Yuson - AdministratorTIME COMPLETED:
02:14 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility using the CARE Tool. LPA Mora met with Ronald Yuson (Administrator) and explained the reason for the visit. The facility is an Adult Residential Facility for Persons with Special Health Care Needs (ARFPSHN) and it is licensed to serve 5 bedridden adults. Facility is operating within the scope of its license.

The facility is in a residential area and it is a one story family home. A tour of the single-story facility included the following: 5 client bedrooms, 2 bathrooms, kitchen, living room, dining room, patio, front yard, backyard, and am attached garage. LPA Mora conducted the tour with Ronald Yuson and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps were observed locked in a kitchen cabinet. Chemical and cleaning solutions are kept locked under the kitchen sink. The First Aid kit is kept locked in the living room and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in the hallway cabinet. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in a cabinet near the kitchen. Client files and staff files are kept in the garage. All bedrooms have all required furniture, lighting, and bedding. All bathrooms were observed with shower mats. The water temperature was tested in both bathrooms and measured at 116.6 degrees F and 115.8 degrees F, which is within the required 105-120 degrees F. A fire extinguisher was observed in the kitchen, living room, and garage and are fully charged. Smoke detectors and carbon monoxides were observed throughout the facility and were operable during the visit. The facility has sprinkler system in place. The emergency generator was last tested on 08/08/23. The front yard and backyard are clean. There is a shaded area with seating in the patio. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.

LPA reviewed medication for all 5 clients and observed that medications are documented properly and given as prescribed. LPA reviewed files for all 5 clients and 5 staff. LPA observed administrator certificate for Ronald S Yuson – 6030693735 with an expiration date of 06/21/2023, but renewal application was received by CCLD on 06/20/23 and it is currently pending. LPA interviewed 2 staff and 1 client. The other 4 clients could not be interview due to being non-verbal. LPA reviewed all 5 clients' P&I funds with Administrator present, and observed no discrepancies. (Continued to LIC 809-C)
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LUBEC HOME
FACILITY NUMBER: 198601880
VISIT DATE: 08/14/2023
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Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
LIC809 (FAS) - (06/04)
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